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Laparoscopic Repair of Inguinal and Femoral Hernia

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Laparoscopic hernia repair is a minimally-invasive procedure to repair the inguinal and femoral hernia. Read this article to know more.

Medically reviewed by

Dr. Shivpal Saini

Published At February 20, 2023
Reviewed AtMarch 2, 2023

Introduction:

A hernia is caused due to the bulging of the contents of the abdomen through a weak area in the abdominal wall. Externally, it looks like a bump, but internally the protrusion is in the shape of an omega (Ω) with a narrow neck. If this bulging happens in the inguinal canal, it is known as an inguinal hernia; if the bulging happens in the femoral canal, it is known as a femoral hernia.

The inguinal canal is located inside the inguinal ligament that runs obliquely from the hip bone to the pubic bone; it acts as a connection between the abdomen and the groin. In men, it contains the sperm cord and the ilioinguinal nerve; in women, it contains the round ligament (to support the womb), the genitofemoral nerve, and the ilioinguinal nerve. The femoral canal is an inverted cone-shaped canal just below the inguinal ligament inside the femoral sheath. The femoral canal contains the lymphatic vessels and one lymph node.

How Does an Inguinal or Femoral Hernia Occur?

An inguinal or femoral hernia occurs when part of the peritoneum (the innermost lining), bowel, or fat protrudes into these canals. If the hernia is made of fat, the characteristic bulge will disappear when direct pressure is applied; however, if it contains the small or large intestine, the bulge will not reduce. At times, the hernia will also get strangulated, a condition during which the muscle surrounding the neck of the hernia will clamp down on the tissue and cut off the blood supply to the content of the hernia. Patients with an incarcerated or strangulated hernia will have the signs and symptoms of bowel obstruction and should be treated immediately to avoid life-threatening complications.

What Are the Causes of Inguinal and Femoral Hernia?

A combination of predisposing risk factors, when combined with medical conditions that increase intra-abdominal pressure, will cause a groin hernia. The predisposing conditions are:

  • Aging- Abdominal muscles grow weaker with age, which makes them lose their stiffness and withholding capacity.

  • Gender- Women are less prone to hernias due to their narrow inguinal and femoral canals.

  • Chronic Constipation- It causes excess strain during bowel movements.

  • Chronic Cough- When coupled with smoking, chronic cough increases the chances of hernia.

  • Previous Pregnancy- Multiple pregnancies weaken the abdominal muscles, predisposing the mother to a hernia.

  • Previous Abdominal Surgeries- Patients with abdominal surgeries like appendectomy, cesarean, etc., are predisposed to hernia due to weakened musculature.

  • Family History- This does not happen often, but if the parent or the patient's sibling has had a hernia, this will increase the chances of the patient developing one too.

Conditions that increase the intra-abdominal pressure are:

  • Strenuous activity.

  • Pregnancy.

  • Chronic cough.

  • Strain during bowel movements and urination.

  • Benign lesions.

What Are the Symptoms of an Inguinal and Femoral Hernia?

Femoral hernia is less common when compared to inguinal hernia, but the chances of incarceration and strangulation are more in the former. The following are the symptoms of a strangulated inguinal and femoral hernia:

  • Abdominal pain quickly intensifies.

  • Discoloration of the hernia.

  • Nausea and vomiting.

  • Abdominal distension.

  • Small bowel obstruction.

  • Absence of flatus (or gas).

  • Paresthesia (prickling feeling) due to the compression of the nearby nerves.

Patients with strangulated groin hernia will need emergency surgery to stop the life-threatening conditions that follow post-strangulation.

What Are the Tests Done to Confirm Inguinal and Femoral Hernia?

Initial diagnosis can be made with a physical examination; the following investigations are done to confirm the diagnosis:

  • Ultrasound- This is helpful in morbidly obese patients in whom detection will be more challenging on a physical exam alone.

  • Computed Tomographic (CT) Scan- Preferred in patients with a suspected incarcerated or strangulated hernia.

Most patients reach out to the emergency once they are symptomatic, which means the hernia has already been strangled; this limits the investigations to prevent further discomfort.

How Are Groin Hernias Treated?

Surgery is the only treatment option for both inguinal and femoral hernias. The goal of the surgery is to move back the contents of the hernia into the abdomen. The gap in the abdominal wall is closed off with a reinforced fine synthetic mesh to prevent a recurrence. There are three different types of hernia surgeries:

  • Open Surgery Without Mesh- Surgery involves one large abdominal incision, the hernia, and its contents are pushed back, and the gap is then sewn together with adjacent connective tissue.

  • Open Surgery With Mesh- The new gap formed after pushing back the hernia into the abdomen is closed with a synthetic mesh to strengthen the abdominal wall.

  • Laparoscopic Surgery- There are two main ways to perform laparoscopic hernia repair-the transabdominal peritoneal approach (TAPP) and the extraperitoneal approach (TEP).

  • Preparation for either of the procedures is similar to any other surgical approach.

  • Preoperative antibiotics and anticoagulants are given to prevent infection and excess bleeding. The patient is given general anesthesia and placed in a supine position, a foley catheter may be placed for urination, but its placement is based on the surgeon’s discretion.

  • TAPP and TEP are similar, except the peritoneum (inner abdominal lining) are incised in the TAPP approach, which will need to be closed with a mesh. Three small incisions are made in the skin, each around 5 mm to 10 mm long, for the placement of trocars. A trocar is a medical device containing an awl (sharp tip), a cannula, and a seal.

  • The location of the incision (also known as a port) is different for TAPP and TEP. In the TAPP technique, the ports are placed in three different locations, they are:

  • One at the umbilicus.

  • The right side of the midclavicular line.

  • The left side of the midclavicular line.

  • In the TEP approach, the ports are straight from the pubic bone to the umbilicus. After the port placement, the surgeon will insert a laparoscope (a fiber-optic instrument with a camera and light attached) through one of the ports; it acts as a guide to survey the surrounding area and perform the procedure.

  • If there are no other abnormalities, the surgeon will insert special surgical instruments through the remaining ports and go ahead with the reduction of the hernia by placing the contents of the hernia back into the abdomen.

  • If there is any clinical concern for incarceration or strangulation, the hernia sac will be opened, followed by an assessment of the viability of the contents. Unsalvageable contents are dissected, and the overlying defect is closed off with a prosthetic mesh.

There is no best method for a hernia repair, but most surgeons prefer the laparoscopic approach due to its minimal postoperative complications and scarring.

What Are the Complications of Surgery?

Recurrence is one of the most common complications after a hernia repair. Risk factors for recurrence include obesity, tobacco use, co-existing infection, collagen tissue disorders, diabetes, and poor nutritional status. Apart from recurrence, immediate complications include bleeding and infection at the incision site; these are common to all abdominal surgeries and can be controlled with efficient post-operative care.

Conclusion:

Accurate diagnosis plays an important role in the treatment of a hernia. The diagnostic dilemma arises due to the non-specific symptoms of a hernia, such as nausea, vomiting, lower abdominal pain, and leukocytosis. Patients should seek medical help when they spot a lump or bump in their lower abdomen, preventing extreme consequences and providing better outcomes from the procedure.

Dr. Shivpal Saini
Dr. Shivpal Saini

General Surgery

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laparoscopyfemoral hernia
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